1. Mental health of irregular migrants in Sweden Alexis Gainza Solenzal Licensed psychologist Group leader of the Rosengrenska Psychiatric team styrelsen@rosengrenska.org www.rosengrenska.org

2. Background: The Rosengrenska foundation Rosengrenska was founded in 1998 with three initial goals: To revoke Rosengrenska To spread knowledge about the health care needs and rights of irregular migrants To offer health care to irregular migrants

3. Background: The Rosengrenska foundation From 1998 - 2004/2005: telephone- coordinated network of health care personnel. In 2004/2005: Rosengrenska opened the clinic that still exists today, one evening per week (most weeks). In the years 2008 – 2015: the clinic was run in cooperation with the Swedish Red Cross. September, 2015: the clinic is once again run solely on a voluntary basis.

4. Background: irregular migrants Irregular migrants are people who stay in Sweden without the necessary authorization or documents required under immigration regulations: People who, for a variety of reasons, never seek asylum. People who have been denied asylum and who have received their deportation notice. People who stay in Sweden even though their temporary visa or temporary residence permit has expired. Children who are born as irregular migrants by having parents who are irregular migrants.

5. Background: Mental health among irregular migrants A comparative survey study in the Netherlands showed that irregular migrants reported a high level of psychological distress but received less treatment than other migrants. Teunissen, van den Bosch, van Bavel, van den Driessen Mareeuw, van den Muijsenbergh, van Weel-Baumgarten & van Weel, 2014 A French comparative study showed that irregular migrants reported worse somatic and mental health issues than any other migrants. Jolivet, Cadot, Florence, Lesieur, Lebas & Chauvin, 2012 In an ongoing Swedish interview study irregular migrants report that they often need to prioritize buying food and paying for living accommodations rather than getting treatment for them and their children. Ascher & Andersson

6. Background: Mental health among Rosengrenska’s patients In the beginning, focus on bodily illnesses. Some patients returned to the clinic many times. Psychosomatic, and/or psychiatric ailments? Counselors, psychologists and psychiatrists were recruited to provide “supportive talks”.

7. Screening of mental health at Rosengrenska Under-reporting of mental health issues was suspected A semi-structured intake interview was developed. Including questions related to sleep, occurrence of nightmares, anxiety and depression.

8. Screening of mental health at Rosengrenska Between February 2013 and June 2014, 288 respondents: 232 came because of bodily illness 30 came because of mental health issues 23 came for other reasons 91 % of the patients who were at Rosengrenska due to bodily issues also reported at least one symptom of mental health problems. Over 25 % had all four symptoms that were screened for. A high demand of counseling, by the end of 2013 a queue of 60+ patients

9. New legislation facilitates access to health care Since July 2013 irregular migrants who are 18 years and older have the same right to health care as asylum seekers. “Health care that cannot be postponed” The bulk of the cost is paid for by the state. Patient fees mostly varies between 5-30€. All children in Sweden have the same right to health care

10. Obstacles to mental health care despite new legislation A gradual shift from providing health care to referring patients to the regular Swedish health care facilities. Patients with mental health problems returned to Rosengrenska in a higher degree than patients with bodily illnesses. Patients with mental health issues reported mistreatment and/or lack of knowledge about the new legislation in the regular health care system.

11. Psychological assessment of mental health at Rosengrenska A group of psychologists began offering assessment interviews to patients reporting mental health issues. The interview is structured to cover suspected psychiatric diagnoses, need of further assessment/treatment, heredity, alcohol and/or drug abuse, bodily status, psychiatric status and assessment of suicidality. The assessment takes between 30 – 90 minutes depending on the complexity of the case.

12. Referrals and follow-up After one year over 60 written referrals had been sent to different mental health care providers. Children were not assessed individually, referrals were sent following the description of the parent. All sent referrals were registered to facilitate follow-up. A “referral confirmation” was added to the structured referral. A new group was formed to systematically request referral confirmations and answers.

13. Results of sent referrals: Mental health care providers

14. Results of sent referrals: Psychiatric symptoms

15. Results of sent referrals: Initial obstacles

16. Results of sent referrals: Established health care

17. Treating mental health among irregular migrants Common misconception that irregular migrants mental health cannot be treated due to ongoing traumas and a difficult life situation. Psychotherapeutic treatment shows good results: Best support for trauma focused CBT and Narrative exposure therapy Solobodin & de Jong, 2015 Good results for narrative exposure therapy when treating PTSD with comorbid depression. Stenmark et al., 2013 Swedish interview study with irregular migrants in psychodynamic psychotherapy: Patients reported improved physical and psychological health, Improved sleep, improved trust and experienced therapy as a support in their roles as parents. Nord, 2014 Pilot study of EMDR in a refugee camp in Syria shows promising results of treating PTSD. Acarturk et al., 2015

18. The psychiatric team of Rosengrenska Counselors, assessment psychologists, psychiatrists and psychology students. The objective for the supportive talks has changed drastically. Today counseling is time-limited and focused on motivating the patient to seek help in the regular mental health system. A decline in psychological assessments has been noticed during the last 6 months.

19. Psychosocial needs As access to mental health care in Sweden is improving for irregular migrants, the psychosocial needs become more evident: Poverty, homelessness, famine, Swedish-language-education and access to preschools for the younger children.

20. Mental health of irregular migrants in Sweden Alexis Gainza Solenzal Licensed psychologist Group leader of the Rosengrenska Psychiatric team styrelsen@rosengrenska.org www.rosengrenska.org